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HomeMy WebLinkAboutBuilding Permit # 12/6/2016 t O RTH BUILDING PERMIT TOWN OF NORTH ANDOVER o APPLICATION FOR,PLAN EXAMINATION `- � ^" t7 Date Received_ . � amen mew Permit Info#:_ SaCHus� Date Issued this page 4J►RTX T:Applicant must complete a items on p y_ L OCATIC31 .._.. �. Print ppep>-ATY OWNE t Print 1 PO.Year Strucure yes no MAP_..PAR.._ CEL: ff-, __ , Histone District yes ZONING DISTRIOria Machine Shop_\lillage�y�s_ no TYPE OF IMPROVEMENT PROPOSED USE _ Non- Residential Residential —— - i I�ew BuiCding D One family 1 [ Two or more family ❑ Industrial D Addition ��ommercial ,'"Alteration _ Na. of units: -. - ❑ Repair, replacement D Assessory Bldg - D Others: U Demolition — - © Other r - ❑ Flood>Eain CI Wetlands Watershed District C1 Septic C7 Well p Water/Sewer DESCRIPTION K T BE � ��r�^yyg g�y�,p C�RI�IED' �F WORK V f"A .,^ r.. Y—/—.f't.� _ Identification.- Please Type or Print Clearly OWNER: Name: Phane Address, _._ actor Name ..i, �, ,� � Contr r Phony. . , AddCess: r, . o ... ,Supervisor's Construction License: C ) °i M exp. Date . _ Florrte lrnproverrtent License' Exp Daten_: w ARCHITECT/ENGINEER Address: L. Reg. No. " FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$920.00 PER S.F. i .Total Project Cost: $ � � �k� FEE: $ �. s ° Check No.: t-,a� n :.. z re re aste�e ,�oratr et©Ps do not Noe- Receipt have-access r°v the gaa, ntw fond ® NOTE: Ye �a�.s wry Signature of c antractor innt�ire,of ACientfOwter __ _.. Plans Submitted Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ ' ypp,-OF SEWERAGE DISPOSAL Public Sewer Tanniug/Massage/BodyArt ❑ Swhmiugfools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tanl�,otc. ❑ permanent Dwnpster an Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE. ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING 85 D VELOPMENT Reviewed On 1 to Signature_ cl CAN of E COMM TS N "Cl CONSERVATION Reviewed on � � Si nature O. A� COMMENTS - HEALTH Reviewed on Si nature COMMENTS � Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Manning Board Decision: Comments Lonservation Decision: Comments 11l!'atCer &Sewer Connection/Si nature& Dale Driveway Permit DPS'Town Engineer: Signature: Located 384 Osgood Street SIRE DEPARTMENT' - Temp Dumpster on site yes no Loeated at 124.Main Street Fire Department signaureldate i rnn�f�lllFNT�; _ ¢ �CI,FtT� _EV1% r-% ver� own . : _ _ '' Aiidqj 0 �" 0 No. blq—c)4 1 h ver, Klass o ®/ d COCM1042Ctll wICn � V BOARD OF HEALTH Food/Kitchen Septic System M An PERMIT T L CERTIFIES THAT ..L..�..I>......� V*'� o �� .• BUILDING INSPECTOR THISC ......................... ........ ...... 3.�.�[ ®.�..�,�.�..�. S� Foundation has permission to erect .......................... buildings on .:...... *� .r I<,i .�... ,4. .,� Chimney to be occupied as ..Z�1.�....3 •_ this mit shall in eve respect conform to the terms of the application Final provided that the personaccepting p rY p on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES 16 MONTHS I ELECTRICAL INSPECTOR UNLESS CONS T N Rough Service •_ " "' ILDING IN CT R Final GAS INSPECTOR Occupancy Permit Required to Occufy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ........................... The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code (780 CMR) Building Permit Application to Construct, Repair,Renovate or Demolish a Building Other than a One-or Two-Family Dwelling Requirements for Building Permits Permit requirements are specified in Chapter 1 of the MA State Building Code. Applicants should review the requirements to avoid common problems. The standard form below incorporates the code requirements and is provided for use by municipalities to achieve permit consistency across the State. Municipalities may use a variant of this form but it must contain at least the same information. Please contact the municipality where the work will be done for the proper form or follow the instructions below if this standard form is acceptable. Filing Instructions • Complete the application. The application is available in Word or PDF format so check to see what is acceptable to the local building official. • Include construction documents, specifications, and other materials required. • mation that property taxes, water fees, etc. are Check if the local municipality requires confir not outstanding. Also, check if the local building official requires construction control forms (see section 107 in the building code) with this application. • Submit the application package with a check made payable to the municipality for the fee as determined by the municipality. Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a livable No. Item Submitted Incomplete Not Re uired 1 Architectural X 2 FtFire undation X 3 ural X 4 Suppression X 5 larm ma re uire re eaters X6 C X 7 Electrical X 8Plumbin (include local connection X 9 Gas Natural,Propane,Medical or other X 10 Surveyed Site Plan Utilities,Wetland,etc.) X 11 Smcifications X 12 Structural Peer Review X 13 Structural Tests&Inspections Program X 14 Fire Protection Narrative Report X 15 Existing Building Survey/Investianon X 16 r Con Eneservation Report X 17 Architectural Access Review 521 CMR *was reviewed T77 s 18 Workers Compensation Insurance x 19 Hazardous Material Mitigation Documentation 20 Other 5 ec' 21 Other(Specify) 22 Other S ecif Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information See John Savasta's contact information Above - Registration Number Name(Registrant) Telephone No. e-mail address Street Address City/Town State Zip Discipline Expiration Date Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address Ci /Town State Zi - - Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address Ci /Town State Zi Please follow this link for construction control forms to be used by Registered Design Professionals. Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location No. and Street City /Yawn Zip Name of Building(if applicable) Assessors Map # Block#and/or Lot# For the above described property the following action was taken: Demo of salt shed only- no existing utilities Water Shut Off? Yes ❑ No ElProvider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricit Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Y Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) commonwealth ofs `aZ19-��exats Departrnent of-rr2dr�st�z ongre Street SWM 100 1 G` Boton,.iVlA.02114�01� � o-v/dl,www.rr�ass.g M 5�* • Wa�kers' Compe�atioxt�r�cB.�davift.Bxrilde�r�1C��U7C�OsR��t7rzciansl�'Irxm�ers. 3 TO PEP3 .E�a WJ'I'g I PEilML I'XN ,jease print Bc 'bl A ' ]scant formation dividual . •� , S c c. Name,(Business/Orga atlanlln ) 1� � � �d . Address: I r Phone#: ` 6 _>o c a x ry City/state/zip, ( rw Type of��a�eaf(�ec�uzxe�]; ro riate box: �Lreyort an ezoptapemYecttlie app p 7 n Ne�vl daxistruciaon empes(coli.and/or parE tame). IeQI Wa a employer th....Ll�.-- loyefozme in 8. �Rerslo cleXiCig 2.n X em a sole proprietor or partnership and have no employees v'an�' any capacity.[Novvorkers'comp.insurance required. 9, ❑I7ep10ilti0It 3,n x am ahorueawnar doing allwarkmyse7f[lTowozkers'comp.insorancerequiredj t 10❑Building addition. coutzactors to conduct au work on my property. S Yaill airs or a.dditians l 1.n Elecical rep. �.nl aro ahomeowner andwill be hiring ` re airs oar addition ensure that all contractors either have workers'cnrnpensation insurance or are sale 72_U P�;timbitg P <'t. Ll pzopzietors-with no employees. 13'.[]Raarea 5❑I am a general contractor;and Z have hiredthe sub_con#actors listed on the attached sheet. 14. Other Thane sob contractors have employees andhavewcrkers'camp.insurance n g❑we are a 0ozpnratioriand its,,Off icers have exezcisedtheirright of�cernptian perIVtGI�c. 1(/},and we IaaYe no erployees_[No workers'comp.insurance required l e are doing all wank andthen bine outside contractozs must submit a new af�€davit ir€dicafing suclr Auyappltcantthatcheckshoit Imustalsofilloutthesectionbelowshowingtheirv�orkers'comper�sationpa3it information' 'Homeowners vrho submrt•t is daVitindic i,i,ada Y Trs that checktbis lio�s.inust atinched gn.additional sheets�e thein r7rorkers'o omp policy'number. state whether oxgotthase,entities hate Conkict� t ren employees. 7fthe sub-e&nLT toxs have employees,they mus p ern to ees. Below is clic policy arad�oli site am an employer t],at is pro-viding-rvor^Icers'carnper2sation irrsur once far°tray Y information. {�n �p n �Sw41`c�c� GD . insurance company�ame ErCpixationDate -53 Policy#or Sel€ivs.UC-#:. L hr o Z� cr, &,vt'r City/�tatelZip. Job Site Address: '36- ds _ s'� a e show'ugfhepol_icynumber and expuatlozr date). ensation policy decIaxataou P Attach a cope'Ofthewoxl�exs' omp _ e arra truedunderMOL 0.152,§25A is a cximinalviolatior� pg yrR/arid ane o to $25Q.QD a Failure to secure coverag req Th one year ixnpxisanroa enc,as well.as civil p exralties in t.b e�orxrx of a STOP W O e violator.A copy of tl statement m.ay bo l'orwUded to the O�oa D"Txvestigatio o the D7A dor jas�axance day against th coverage varifzcatiorz. Haat the -nromadon p:'oviclecl above is true a carred do riere7�y certify u er a andpencalties afperjary Si acute' r— Phnrse 0 ficial use only. Dn not-write in Min area,to he carrrplefed by city ar totvra official f Y eritlLxeerase# City or T O-v : critic owe): F p ector Zssui7xgAvithaxity( e axi�raent 3.CxtylToSvC1e�I �.Electxzcallr�s ectax 5.1'luxnToirxgxt l.Board otL T ealtbL 2.Btt i]ding D P 6.Other Phone#- Contact Berson: ----MON LDRUSSO-01 TAYER '4���� CERTIFICATE OF LIABILITY INSURANCE DAT1/9/2o1YYYY) 1119!2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 CONTACT NAME: HUB International New England PHONE 275 Great Road (N_ o,EM)(978)_2639-577 — 263-4189 c Acton, -- MA 01720-4739 E-MAIL ADDRESS: INSURERS}AFFORDING COVERAGE NAIC# _—_-- — ------------ INSURER A:UrllOn Ir1SUrarlCe Company25844 -- -- -- INSURED -- INsuRER B:Acadia Insurance Company ;31325 L.D.Russo,Inc. INSURER C 198 Ayer Road y INSURER D Harvard,MA 01451 INSURER E INSURER r: I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LLIMITSLTR TYPE OF INSURANCE POLICY NUMBER MM/DDtYYYY "`"-- A X COMMERCIAL GENERAL LIABILITY IEACH OCCURRENCE $ 1,000,000 250 OCCUR CLAIMS-MADE f X X CPA011376521 0610112016'10610112017 -DAMAGI=TORENTE[5 — 000 --- LX. PREMISES(Ea occurmn_ce)_ $ � MED EXP{Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 — — --- GEN'LAGGREGATE LIMIT APPLIES PER: !GENERAL AGGREGATE S 2,000,000 POLICY PRO- --- -- �_ u -_ ,000,000 Loc ,$ JECT PRODUCTS-COMPIOP AGG OTHER: $ AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT $ 1,000,000 (iwa accidontl_.. - A ANY AUTO MAA011376621 06101!201$ 06!0112017. BODILYINJURY(Perperson) S ALLOWNEDSCHEDULED - --_-_ AUTOS X AUTOS BODILY INJURY(Per accident) $ XX NON-OWNED E PROPERTY DAMAGE AUTOS _.... L.S---- __.. HIREDAUTOS AUTOS I UMBRELLA B X EXCESS ABne X CLAIMS-MADE X X ,CUA01137671 0610112016110610112017 AGGREGATE $ 10,000,000 {OCCUR _- � AGGREGATE 3 10,000,000 DED X RETENTION 01 $ WORKERS COMPENSATION Y!N X STATUTE DENT 0TH- PER — — B ANY PROPRIEAND �ORlPARBN RlFXFCUTIVE X WCA5057245 06/0112016�'06101!2017� E,L.EACH Accl $ 1,000,000 OFFICER/MEMBER FXCLUDED? N NIA 1..__.. ---._ - _— _— (Mandatory In NH) { E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION un OPERATIONS below I ... ----..........................__..------ ----- yes, escn a un or �, E,L.DISEASE-POLICY LIMIT $ 1,000,000 I I DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD IUi,Additional Remarks Schedule,may be attached it more space Is required) 11-9-16 Project:North Andover improvements to the Public Works Facility. Town of North Andover is listed as additional insured on a primary non-contributory basis for ongoing and completed operations with respect to General Liability and Umbrella policies where required by written contract. Waiver of subrogation in favor of the additional insured with respect to the General Liability,Umbrella and Workers Compensation policies where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To ToMain Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ?V�T ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CSS Architects Inc. TRANSMITTAL 107 Audubon Road Tel. 781-245-8400 Building 2,Suite 300 Fax: 781-245-9372 Wakefield, MA 01880 Email: cssa@cssarchitects.com TO Attn: Nat Coughlin Date: 11/14/16 Project No.: 1165 Re: Improvements to the Public Warks L.D. Russo, Inc. Building, North Andover 198 Ayer Road Harvard, MA 01451 SENT VIA: ❑Fax(No. ) ( of Pages Sent: ) F1 Under Separate Cover EPick Up ❑Mail ncourier El Hand Carried ❑Overnight ❑'Other: THE FOLLOWING: ®Drawings ❑Strop Drawings ❑Samples Specifications ❑Product Literature F-1 Change Order El ITEM Caries........:..............Date........... :_ Na. ....,,,, Description........................... ... .......................ry................,........,.,,............,..,,,,......»............................... ... ......„............................,..,,..........................., 2 9/14/16 3 �ignd 1n,d,§tamped Construction Document Drawings ...................................................................._..,......... 1 9/14/16 Signed and Stamped Construction Do,curnent.. .perificat on .............................................__............................... .........................................u....,..............,......;....................,.._-.........................................,....................................................................... ...............,........,.,.....,,,.................,,,............................ _........ .............._......................... ........................,.;........................,..,......,.,.........................,......,.,..............................,........................................._..................................................,........,.....,,.......... .......................................................,...................,_.,.._.....................................................................................................e............ ............................,..................,...,........................,,.........,,,...,.....,..,...... ❑For your information ❑Far review and comment ❑For your use ®As requested ❑Forapproval ❑Forselection ❑Other. [:]No exceptions taken ❑Make corrections noted ❑Amend and resubmit ❑Rejected REMARKS COPIES TO: (with enclosures) CSS ARcl,19TEC'TS UNC. 1165 Transmittal ❑ ❑-® :. _. :e:: :...:: ❑ SIGNED El John Tomaz I Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-099756 Construction Supervisor NATHANIEL PCOUGH-11N z-. �;- 22 BROMFIELD STRE NEWBURYPORT MA` � ZU CA— Expiration: Commissioner 07/22/2017